Stroke Research Fellowship Application
Applicant Information
Full Name:
Date:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
Phone:
State
Email:
ZIP Code
SS No:
YES
NO
Are you a citizen of the United States?
If no, what is your current visa?
Have you ever been party to any
malpractice liability claims, suits, and/or
settlements?
YES
Are you currently licensed to practice
medicine?
YES
Has your license ever been suspended,
revoked, or voluntarily surrendered?
YES
Have you ever been disciplined, in any
way, by a licensing board?
YES
Have you ever been convicted of a crime,
other than a minor traffic violation?
YES
NO
If yes, please attach summary.
NO
If yes please attach copy of license.
NO
If yes, please attach explanation.
NO
If yes, please attach explanation.
NO
If yes, please attach explanation.
References
Please list contact information for your three references. Please request that letters of recommendations be
addressed to The Stroke Research Fellow Selection Committee. Letters should be sent to Ms. Reena Black,
Dept. of Neurology, 1161 21st Avenue South, MCN A-0118, Nashville, TN 37232
Full Name:
Phone:
Institution:
Title:
Address:
Full Name:
Phone:
Institution:
Title:
Address:
1
Full Name:
Phone:
Institution:
Title:
Address:
Military Service
Are you active duty in Armed forces?
YES
NO
Branch:
Rank:
From:
To:
Reserve or National Guard Status:
Are you obligated, through a health professions loan, for military obligation?
YES
NO
Disclaimer and Signature
“In compliance with federal law, including the provisions of Title IX of the Education Amendments of 1972,
Sections 503 and 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990,
Vanderbilt University does not discriminate on the basis of race sex, religion, national or ethnic origin, age,
disability, or military service in its administration of educational policies, programs, or activities; its admissions
policies; scholarship and loan programs; athletic or other University-administered programs; or employment.
Inquires or complaints should be directed to the Opportunity Development Officer, Baker Building, Box 1809
Station B, Nashville, TN 37235. Telephone (615) 322-4705 (V/TDD); fax (615) 421-6871.”
If I accept the appointment as research fellow at Vanderbilt University Medical Center I agree to serve the full
term and to abide by the rules and regulations of the Medical Center and Service to which I am attached.
I certify that the information provided in this application is true and correct.
Signature:
Date:
2